Hybrid Treatment of Critical Ischemia by Popliteo-pedal Bypass Downstream from an Endovascular Femoro-popliteal Recanalisation

The patients presenting with critical ischemia of the lower extremities often have multi-segmental occlusive lesions which cannot be treated either with a bypass, because of the lack of venous material, nor with endovascular techniques because of extensive lesions and calcifications. A hybrid treatment, with a proximal femoro-popliteal bypass and a distal transluminal angioplasty (TLA) was proposed by several authors, with suboptimal results due to the degradation of the downstream network. Due to our large experience of distal and pedal bypasses, we decided to treat these patients in an opposite way: proximal angioplasty and popliteo-pedal downstream bypass, this last using a second choice venous material in the absence of an adequate greater saphenous vein (GSV).